September 2021 by San Diego Physician

Official Publication of SDCMS SEPTEMBER 2021

THE AMERICAN MEDICAL ASSOCIATION Meeting New Challenges

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Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder OFFICERS President: Sergio R. Flores, MD President–Elect: Toluwalase (Lase) A. Ajayi, MD Secretary: Nicholas (Dr. Nick) J. Yphantides, MD, MPH Treasurer: Heidi M. Meyer, MD Immediate Past President: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

Contents SEPTEMBER

VOLUME 108, NUMBER 8

GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD, MPH Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti S. Mehta, MD (Board Representative to the Executive Committee) La Jolla #2: David E.J. Bazzo, MD, FAAFP La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS North County #1: Arlene J. Morales, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Nina Chaya, MD South Bay #1: Paul J. Manos, DO South Bay #2: Maria T. Carriedo-Ceniceros, MD AT–LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Medical Student: Jimmy Yu Resident: Nicole L. Herrick, MD Young Physician: Brian J. Rebolledo, MD Retired Physician: Mitsuo Tomita, MD CMA OFFICERS AND TRUSTEES Robert E. Wailes, MD William T–C Tseng, MD, MPH Sergio R. Flores, MD Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM AMA DELEGATES AND ALTERNATE DELEGATES District I: James T. Hay, MD District I Alternate: Mihir Y. Parikh, MD District I At–Large: Albert Ray, MD District I At–Large: Robert E. Hertzka, MD District I At–Large: Theodore M. Mazer, MD District I At–Large: Kyle P. Edmonds, MD District I At–Large Alternate: David E.J. Bazzo, MD, FAAFP District I At–Large Alternate: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM CMA DELEGATES District I: Karrar H. Ali, DO, MPH District I: Steven L.W. Chen, MD, FACS, MBA District I: Franklin M. Martin, MD, FACS District I: Vimal I. Nanavati, MD, FACC, FSCAI District I: Peter O. Raudaskoski, MD District I: Kosala Samarasinghe, MD District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM District I: Mark W. Sornson, MD District I: Wynnshang (Wayne) C. Sun, MD District I: Patrick A. Tellez, MD, MHSA, MPH RFS: Rachel Buehler Van Hollebeke, MD

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

Feature

American Medical Association Membership Grows While Dramatically Meeting New Challenges By Albert X. Ray, MD and Ted Mazer, MD

Departments

Open Notes in Healthcare By Chad Anguilm, MBA, Richard F. Cahill, JD, and Kathleen Stillwell, MPA/HAS, RN

Briefly Noted: Patient Care • Public Health • COVID-19 Vaccines

Waves of Wellness Soiree 2021 By Adama Dyoniziak

The Science Supporting the U.S. Case for COVID Boosters By Kristina Fiore

Unmasking the Effects of the Pandemic in Eyelid Surgery By Srinivas Iyengar, MD

Clarity on COVID Count By Judith Graham

California Supreme Court Will Hear CMA Lawsuit Against Aetna By California Medical Association Staff

Signal from Noise By Daniel J. Bressler, MD, FACP

Classifieds SanDiegoPhysician.org

BRIEFLY NOTED 2

September 2021

PATIENT CARE

Aetna Creates New Obstacle to Care for Seniors, Highlighting Need for Prior Authorization Reform By California Medical Association ONE OF THE NATION’S LARGEST HEALTH insurance companies has created new bureaucratic hurdles for patients that could prevent many from receiving cataract surgery — part of a trend of insurance companies creating new “prior authorization” requirements that create hurdles for patients and physicians, reduce availability of healthcare services, and increase insurance company profits at the expense of patient care. As of July 1, 2021, Aetna is requiring all cataract surgeries to be “pre-certified.” Aetna claims the practice will “help members avoid unnecessary surgery.” The reality is that this bureaucratic roadblock is not some kind of patient protection measure. It is an effort to deny care and pad the insurance company’s bottom line. It has become common practice for health insurance companies to create new obstacles for patients in hopes of not having to provide essential healthcare to those who need it. The reason for these types of obstacles is simple: Fewer surgeries performed translates to larger insurance company profits. Like other insurance companies, Aetna has enjoyed record profits through the COVID-19 pandemic. The company, which was acquired by CVS Health in 2018, saw its operating income increase from $1.06 billion in 2019 to $3.07 billion in 2020. The California Medical Association (CMA) continues to fight for medical decisions to be made by trained medical professionals instead of lay entities more concerned with the corporate bottom line than the quality of patient care. This is why CMA is fighting to strengthen the prohibition on the corporate practice of medicine, and why we are supporting legislation at the state and federal levels that would streamline and standardize prior authorization requirements.

In California, CMA is sponsoring SB 250 by Senator Richard Pan, MD. SB 250 would require state regulators to streamline the prior authorization system to ensure patients have access to critical care. One successful approach taken in other states is an audit-based system where prospective prior authorization is waived for clinicians deemed high-performing. Texas, for example, recently passed legislation that prevents insurers from imposing prior authorization requirements on providers who have historically high approval rates. CMA is also supporting federal legislation — HR 3173, the “Improving Seniors’ Timely Access to Care Act” authored by California Congressman Ami Bera, MD — that seeks to standardize and streamline prior authorization processes for routinely approved items and services performed under Medicare Advantage programs, among other improvements. Prior authorization requirements can be challenging for patients, creating barriers to care and increasing administrative burdens for physicians who must spend time and resources to get approvals as insurance companies design and administer increasingly complex prior authorization systems. The time delays and administrative burdens also continue to undermine healthcare outcomes. Most startlingly, in a 2020 American Medical Association survey, 30% of physicians reported that prior authorization led to a serious adverse event for a patient in their care such as hospitalization, medical intervention to prevent permanent impairment, or even disability or death. CMA strongly supports SB 250 and HR 3173, both of which would place patient needs first by simplifying and streamlining the prior authorization processes.

TRUST PUBLIC HEALTH

California Healthcare Workers Must Be Fully Vaccinated by Sept. 30 CALIFORNIA HEALTHCARE workers have until Sept. 30, 2021, to be fully vaccinated against COVID-19, under an order issued by Tomás J. Aragón, MD, the state’s public health officer. The new requirement tightens the earlier announcement made by Gov. Gavin Newsom in late July that healthcare workers and state employees must be vaccinated or submit to weekly testing. Between now and the Sept. 30 deadline, employees of hospitals, nursing homes, physician offices, clinics, and other medical facilities must either be vaccinated or undergo mandatory weekly testing, under Gov. Newsom’s previous order issued. The California Medical Association is reviewing this new information and will continue to provide updates on these guidelines. For any additional questions, please contact our Member Resource Center at (800) 786-4262 or memberservice@cmadocs.org.

COVID-19 VACCINES

CDPH Issues Guidance on Coadministration of COVID-19 and Other Vaccines THE CALIFORNIA DEPARTMENT OF PUBLIC Health (CDPH) has issued guidance on coadministration of COVID-19 vaccines with other vaccines. The guidance states that COVID-19 vaccines and other vaccines may be administered without regard to timing. This includes simultaneous administration of COVID-19 vaccine and other vaccines on the same day, as well as coadministration within 14 days. The benefits of coadministration and timely catch up on vaccinations outweigh any theoretical risk. The American Academy of Pediatrics (AAP) also recommends vaccination for eligible children ages 12 and older with the federally authorized COVID-19 vaccine and supports coadministration of the COVID-19 vaccine with routine immunizations—particularly for children and teens who are behind on their immunizations.

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American Medical Association Membership Grows While Dramatically Meeting New Challenges Diversity in Medicine and Protecting Physicians from Regulatory and Scope of Practice Challenges Are Key BY ALBERT X. RAY, MD AND TED MAZER, MD

September 2021

ANY HAVE CLAIMED

that the American Medical Association lost its way in the era of “Bowling Alone,” but the numbers tell a different story. According to CEO/EVP James Madera, MD, “Dues-paying membership has increased 35% since 2011 … Last year, amid the worst public health crisis in a century, the AMA continued its remarkable rise, recording its highest year-overyear growth since 1948.” Why this increase in membership? No one is sure, but the AMA has been a strong voice for public health throughout the pandemic and before, advocating for patients and physicians in state houses, regulatory agencies, and the hallways of Washington, DC. While staunchly protecting the viability of medical practices, the AMA’s increasing focus on public safety, access, and cost issues may have stimulated growth of student and young physician membership — a huge positive, as these new generations of physicians are indeed the future of healthcare in the U.S. The importance of their participation in setting AMA policy cannot be overstated. The AMA focuses on these new and future doctors through digital communications and programs like Members Move Medicine. The AMA’s leadership and voice throughout the COVID-19 crisis seems to be assuring many young physicians and students that they can find their voice through the AMA. Over the past decade and more, the AMA has been critical in protecting physicians from even more regulatory overreach and scope creep, in turn protecting patients’ access to high-quality, welltrained professionals. While many of us are unhappy with our current regulatory and economic environment, undeniably things would have been much worse without the ongoing efforts of organized medicine. The AMA, along with state medical associations including the California Medical Association, has been hard at work during the pandemic, collaborating with government, scientists, physicians, and the entire healthcare system to control the outbreak and improve access to vaccinations and other needed services.

Left: Dr. Albert X. Ray (l) and Dr. Ted Mazer (r) representing the California delegation to the 2019 American Medical Association’s House of Delegates. Above left: SDCMS Board Member and AMA Ambassador Kyple P. Edmonds, MD, looking stylish while organizing testimony for an upcoming resolution. Above center: San Diego’s Dr. Holly Yang attended the AMA’s 2019 Annual House of Delegates as an Alternate Delegate. She now serves as one of California’s delegates to the American Medical Association’s HOD. Above right: Dr. Ajayi testifies to the AMA House of Delegates during the annual meeting in Chicago.

Access to care during the pandemic refocused awareness on health equity and social justice. At the June AMA House of Delegates meeting, held virtually due to the pandemic, the AMA continued its work on recognizing social and health disparities and justice issues, and continued its tradition of open and sometimes heady debate regarding healthcare access for all, while striving to protect the sacrosanct physician-patient relationship and the profession of medicine. The five-day meeting included heated discussions about a new diversity-oriented strategic plan as well as new scope-ofpractice intrusions, including the recent move by PAs to rebrand themselves as “physician associates” and seek broader independent practice. Practice viability and resident debt in the age of COVID-19 were also hotly discussed, along with many other issues. As in any organization that has grown along with our evolving American history, the AMA seeks to acknowledge its past errors, highlight its successes, and build on them, while addressing new issues that impact physicians, their patients, and the health of America. The AMA Committee on Ethics advocated for recognition of qualified female physicians in 1869, and the AMA inducted its first female member, Sarah Hackett Stevenson, in 1876. In 1998, Nancy W. Dickey, in AMA leadership since 1977, became the first woman named as AMA president. Now, for the first time in its history, the AMA has had three consecutive female physicians as president. In the 1970s, the AMA spoke out against gender discrimination in medical

institutions, and in 1975, AMA adopted a policy stating that “discrimination based on sexual orientation is improper and unacceptable by any part of the federation of medicine.” In 1995, Lonnie R. Bristow became the first African-American president of the American Medical Association, having also been the first African-American member of the Board of Trustees and its first African-American chair. In 2008, the AMA issued a formal apology for previous policies that excluded African-Americans from the organization, sadly advocated by its founder, Dr. Nathan Davis, in a bygone era, and announced increased efforts to increase minority physician participation in the AMA. In June 2019, Patrice A. Harris, MD, MA, a psychiatrist from Atlanta, became the AMA’s 174th president and the organization’s first AfricanAmerican woman to hold this position. In what has generated a great deal of ongoing discussion, this year the AMA published a plan to dismantle “structural racism.” This plan encourages “explicit conversations about power, racism, gender, and class oppression, forms of discrimination and exclusion.” The plan asserts that people of different backgrounds may need to be treated differently to compensate for prior disadvantages and commits to “dismantle white supremacy.” During the recent virtual House of Delegates meeting, solid agreement emerged about the need for diversity and to address shortcomings in American healthcare, but strong feelings arose regarding specific language and concepts. The spirited discussion around health

equity will continue at the Interim AMA meeting in November, hopefully in person, along with debates on other timely subjects, ranging from healthcare financing reforms to medical training debt, scope of practice, immigration health issues, and public health issues, including ongoing COVID-19 matters and preparedness for future possible pandemics. The remarkable growth of AMA membership demonstrates the critical role that the AMA and organized medicine can play in times of public health emergencies while protecting our patients, practicing safely, and remaining financially viable. With greater strength in numbers comes greater influence in the U.S. Capitol and state houses across the nation. Your AMA, like any major organization with more than 150 years of history, must evolve and change with the times, revising policies and approaches. Today’s AMA stands strong on the forefront of healthcare access and practice needs, on the response to the COVID-19 pandemic, and on improving access to care for all communities, particularly historically underserved communities.

Dr. Ray served as president of the San Diego Academy of Family Physicians, president of the San Diego County Medical Society, and as a trustee of the California Medical Association. He is chair of the California Delegation to the American Medical Association. Dr. Mazer is a former president of the San Diego County Medical Society and former president of the California Medical Association.

SanDiegoPhysician.org

SOIRÉE 2021 BY ADAMA DYO NIZIAK

A HUGE THANK-YOU TO EVERYONE WHO CAME to, or otherwise supported, the Champions for Health 2021 Waves of Wellness Soirée. We were delighted with the energy and engagement of the audience that helped us raise critical funds for our flagship program, Project Access San Diego. Champions for Health (CFH) is very grateful to our sponsors, American Medical Response, San Diego County Medical Society, Vituity Medical Group, Point Loma Nazarene University, Cooperative of American Physicians, Aldrich Advisors, Molina Healthcare, ASMG, and ZWJ for their contribution to an incredible evening. A big thanks also goes to CFH’s board of directors and the development committee for making the evening a huge success. This year’s theme was “Waves of Wellness,” and seahorses were the symbol of hope and healing. Seahorses are ascribed healing and magical powers, bringing positive energy and hope to all they come in contact with, much like the medical community. A beneficiary of Project Access San Diego, Karla, spoke to the audience about the way this program gave her an opportunity and saved her life. She spoke about her dire health situation — rheumatic mitral valve disease of the heart — before she was helped with life-saving surgery performed by Dr. John Tyner of Scripps Green Clinic, and how she is thriving today. There wasn’t a dry eye in the audience! Awardees were recognized for their contributions

September 2021

to Project Access. Honorees include: President’s Award, Northgate Gonzalez Market; Civic Health Leader of the Year, Kristin Gaspar; Volunteer Physician of the Year, Varuna Raizada, MD; Facility of the Year, Core Orthopaedic; Partner of the Year, TrueCare; Medical Interpreter of the Year, Holly Araya; and Champion of the Year, Dhruvil Gandhi, MD. Access to care for all is the mission of Champions for Health — it shouldn’t be a dream that is out of reach. The physicians of the San Diego County Medical Society made a promise to the vulnerable populations of San Diego when they formed Champions for Health, and Project Access was a twinkle in their eye, just a dream that is now a reality. We are grateful to the many who have so generously supported and continue to support Project Access in myriad ways. If you missed the soirée and would like to make a gift, please go to www.championsforhealth.org/donate. Your gift shows your support for the safety net that is provided by volunteer physicians to your neighbors who are most in need of procedures and surgeries. You can also make a difference in the lives of uninsured San Diego County residents by volunteering your physician expertise. Please go to www.championsforhealth.org/volunteer. Adama Dyoniziak is executive director of Champions for Health.

Dinner

Kristin Gaspar and Paul Hegyi

Adama Dyoniziak and Dr. Dhruvil Gandhi

Melissa Lujan, Mireya Banuelos, Jaime Carrillo, Marti Brentnall, Evelyn Moua, Shaina Gross, Anita Darling, Ricardo Corona, and Marianna Corona

TrueCare CEO Michelle Gonzalez and Celene Salazar

CHAMPION SOIRÉE

Champions for Health’s board

Lynn and Dr. Peter Raudoskoski, and Dr. Albert Ray

Dr. Wendi Buchi and Dr. Laurie Greenberg of IGO, and Michael Winer

Kathy Hahn and Al Amiri of Aldrich Advisors

Dr. Ted Mazer and Marcy Mazer

Dr. Holly Yang and Dr. Ted Mazer walk through the aquarium

Erica Salcuni and Grossmont Healthcare District CEO Christian Wallis

Renee Wailes, Dr. Robert Wailes, Sabrina Bazzo, Dr. David Bazzo, Dr. Holly Yang, Christina Flores, Dr. Sergio Flores

Dr. Jim Schultz and Miguel Gonzalez of Northgate Gonzalez Market

SanDiegoPhysician.org

INFECTIOUS DISEASE

The Science Supporting the U.S. Case for COVID Boosters Three MMWR studies, Mayo Clinic Data, and Unpublished CDC Data Prop Up Need for Third Dose BY KRISTINA FIORE

.S. HEALTH OFFICIALS

recently laid out the scientific rationale for a third dose of the COVID-19 mRNA vaccines for all U.S. adults, relying on published and unpublished CDC data, as well as a preprint study. Overall, they said that there is evidence that vaccine effectiveness against infection — both symptomatic and asymptomatic — has been decreasing over time, but that protection against severe disease, hospitalization, and death remains relatively high. In anticipation of further waning of immunity amid the ongoing delta variant-fueled surge — which is posing additional challenges — pulling the trigger on booster shots could help the U.S. stay ahead of the virus, they said. During a White House COVID-19 task force briefing, CDC Director Rochelle Walensky, MD, offered five pieces of 8

September 2021

evidence to support the move: three new studies published in the Morbidity and Mortality Weekly Report (MMWR), one previously published on medRxiv, and unpublished CDC data on the delta variant.

Protection Against Infection Walensky cited new MMWR data from New York that showed a decline in vaccine effectiveness against infection, from 91.7% to 79.8% during the period of May 3 to July 25. Eli Rosenberg, PhD, of the New York State Department of Health, and colleagues linked data from several New York surveillance systems on immunization, lab testing, and hospitalization. During that time period, they found that a total of 9,675 new cases of COVID-19 occurred among fully vaccinated adults compared with 38,505 cases among unvaccinated adults (1.31 vs 10.69

per 100,000 person-days). In addition, data from the Mayo Clinic, published previously on medRxiv, similarly found a decrease in vaccine efficacy in preventing infection in Minnesota, Walensky said. For the Moderna vaccine, effectiveness against infection fell from 86% in January–July, down to 76% during the month of July, while it fell from 76% down to 42% for Pfizer during that time. Finally, new data from MMWR from a national network of nursing homes showed a reduction in protection against infection, from 75% in March to 53% as of Aug. 1, Walensky said. Srinivas Nanduri, MD, of the CDC, and colleagues assessed weekly data on nursing homes and skilled nursing facilities reported by CMS to the CDC’s National Healthcare Safety Network. They found that the adjusted effectiveness against infection during the “pre-delta” period (March 1 to May 9) was

50 surgeries given 30 consultations provided 80 lives changed... be part of the change.

“As a practicing physician, volunteering for Champions for Health is perfect.” “The process is simple. You receive medical information in advance to optimize the patient and physician

It’s easier than you think to volunteer in your community.

time during consultations. You get to provide state-of-the-art care in top-notch hospitals. I still receive thank you cards from Champions for Health patients I had years ago. It is so rewarding to transform people’s lives.” — Dr Hernan Goldsztein, Otolaryngologist-Head and Neck Surgeon.

Join us at championsforhealth.org/volunteer/ Join our community of volunteers and provide pro bono specialty medical services in your office through the Champions for Health Project Access San Diego program. We make it easy for you and your office team to provide much-needed medical care to uninsured, low-income adults in our community. SanDiegoPhysician.org

74.7% (based on 17,407 weekly reports from 3,862 facilities), which fell to 67.5% in the “intermediate” period (May 10 to June 20; based on 33,160 weekly reports from 11,581 facilities), and ultimately to 53.1% during the delta dominant period (June 21 to Aug. 1; based on 85,593 weekly reports from 14,917 facilities). Nanduri and colleagues noted that estimates of effectiveness were similar for both vaccines. “Taken together, you can see that while the exact percentage of vaccine efficacy differs depending on the cohort and setting studied, the data consistently demonstrate a reduction in protection from infection over time,” Walensky said.

Protection Against Severe Illness and Hospitalization Walensky noted that despite the waning in efficacy against infection, data suggest that the vaccines are still highly protective against severe illness and hospitalization. The New York MMWR data showed that from May 3 to July 25, the overall ageadjusted vaccine effectiveness against hospitalization was relatively stable (91.9% to 95.3%). Additionally, there were a total of 1,271 new hospitalizations among fully vaccinated people, compared with 7,308 hospitalizations among the unvaccinated (0.17 vs 2.03 per 100,000 person-days), Rosenberg and colleagues reported. Hospitalization rates declined through the week of July 5, but increased during the weeks of July 12 and July 19, they added. Hospitalization rates were also higher among those 65 and up, they found. The Mayo Clinic preprint found that from January to July in Minnesota, both the Moderna and Pfizer vaccines were effective at protecting against COVIDassociated hospitalization (91.6% vs 85%, respectively) and ICU admission (93.3% vs 87%, respectively). There were no deaths in either cohort. Finally, new MMWR data from CDC’s IVY (Influenza and Other Viruses in the Acutely Ill) Network reported by Mark Tenforde, MD, PhD, of the CDC, and colleagues showed no decline in vaccine efficacy against hospitalization over 24 weeks — though Walensky noted that the cohort was short on delta infections. 10

September 2021

The authors assessed IVY-collected data on 3,089 hospitalized adults from 21 hospitals in 18 states from March 11 to July 14. Of these, 1,194 were COVID-19 patients and 1,895 were controls who didn’t have COVID-19. Overall, 11.8% of cases were fully vaccinated, as were 52.1% of controls. The efficacy rate against hospitalization was 86% overall and 90% among adults without immunocompromising conditions, they reported. Additionally, of the 1,129 patients who’d received two doses of an mRNA vaccine, there was no decline in efficacy against hospitalization during a 24-week period, with an efficacy rate of 86% from two to 12 weeks after vaccination compared with 84% at 13 to 24 weeks post-vaccination. However, of the 454 samples that had whole-genome sequencing, just 16.3% turned out to be the delta variant, which now accounts for the vast majority of cases. More than half (53.3%) were of the alpha lineage. “Taken together, these data confirm that while protection against infection may decrease over time, protection against severe disease and hospitalization is currently holding up pretty well,” Walensky said. “As we make decisions about boosters, though, we also have to look at vaccine efficacy in the specific context of the delta variant.”

Double Whammy: Waning Immunity and Delta Walensky then highlighted preliminary unpublished data from two of the CDC’s vaccine effectiveness cohorts that included more than 4,000 healthcare workers, first responders, and other frontline workers from eight locations across the U.S. Data through Aug. 6 showed waning effectiveness against symptomatic and asymptomatic infection in the context of the delta variant, from 92% prior to delta, to 64% with delta. She noted that the analysis didn’t show differences over time, which suggests that vaccine efficacy is diminished against delta independent of when a person was vaccinated — meaning full vaccination may be less effective against delta than against previous variants, she said.

Immunological Basis for Boosters Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, provided the immunological evidence supporting the case for a third shot during the briefing. Antibody levels decline over time, he said, but mRNA booster shots would increase antibody titers by at least tenfold. Higher levels of antibodies are associated with better vaccine effectiveness and are likely required to protect against the delta variant, he noted. A paper published in Science showed that antibody levels peaked around 43 days after the second dose of Moderna, but fell by 209 days regardless of the variant involved. Additionally, a preprint published in medRxiv based on phase III data from the Moderna trial looked at “correlates of immunity,” finding that a serum neutralizing titer of 1:100 produces a vaccine efficacy rate of 91%. Thus, the higher the neutralizing titer, the higher the efficacy of the vaccine, Fauci explained. The Science paper, as well as Pfizer data published in the New England Journal of Medicine, showed diminished levels of neutralizing antibody titers with delta compared with other variants, Fauci noted. Finally, another medRxiv preprint showed that a third dose of Moderna increased antibody titers at least 10-fold, he said, and Pfizer recently announced similar data. The Moderna study showed a “remarkable increase in titers” 15 days after the third dose against wild-type virus, the beta variant, and the gamma variant, Fauci said, adding that Pfizer data also showed a good boost in levels against the delta variant, which is expected to be similar for Moderna. “All of this supports the use of a third booster mRNA immunization to increase the overall level of protection,” Fauci concluded. Kristina Fiore leads MedPage’s enterprise and investigative reporting team. She’s been a medical journalist for more than a decade. This article originally appeared in MedPage Today.

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VISION SURGERY

Unmasking the Effects of the Pandemic in Eyelid Surgery BY SRINIVAS IYENGAR, MD

T IS NO SECRET THAT PEOPLE ARE SEEKING OUT

aesthetic procedures more than ever, and this part of healthcare has become a booming industry. Botulinum toxin, first used by eye surgeons for the treatment of paralytic strabismus, was routinely used in the treatment of facial rhytids (wrinkles) prior to the pandemic, and many other companies besides Allergan (now AbbVie) have jumped on the bandwagon looking to develop their own neuromodulator. Medical students in the early 2000s studying for their USMLE exam would have never guessed that inhibiting the release of acetylcholine into the synaptic cleft from the presynaptic motor neuron would become a billion-dollar enterprise. Nearly two decades ago, patients using bimatoprost, a prostaglandin-analogue eye drop used to reduce intraocular pressure were complaining to their eye surgeons about how their eyelashes were growing longer. Once again, astute entrepreneurs saw a role for this in the aesthetic industry. Latisse, a product carried in many aesthetic practices, is a topical application of this same drug, bimatoprost, to help increase eyelash growth as a cosmetic enhancement. Phenylephrine eyedrops, routinely used in the dilated ophthalmic examination, have the side effect of stimulating Mueller’s muscle, one of the two muscles responsible for eyelid elevation. Take a look at your eyelid position, or a “selfie,” the next time you have a dilated eye exam. Patients who see this effect often ask if they could take home these eyedrops, but forget that the eyedrop also causes dilation of the pupil. In July 2020, the FDA approved the use of topical ophthalmic use of oxymetazoline (Upneeq) that stimulates Mueller’s muscle and makes eyes look more open without causing pupillary dilation. Nonsurgical cosmetic procedures surging over the last few decades have also included various fillers, laser procedures, and most recently, radiofrequency modalities. In August 2020, The New York Times published an article on the surge of interest in cosmetic surgical procedures titled, “Don’t Like What You See on Zoom? Get a Face-Lift and Join the Crowd,” recognizing the surge in not just cosmetic procedures, but cosmetic surgery. In the upper face, there are a few reasons for the surge in these aesthetic surgical procedures. First, the wearing of masks highlights the upper face; we rely on that area to express our emotions. As debates ensue of how to safely return to school, children have adapted to read cues from the what they see above the mask—expressions their teachers and peers, give them with 12

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their eyes and eyelids. With everyone looking at everyone else’s upper face, as well as their own, the interest in rejuvenating that area is not unexpected. The saying “The eyes are the windows to the soul” now also includes them being the windows to our general disposition. With the use of Zoom, Microsoft Teams, and other virtual conferencing applications, people are looking at themselves more than ever on screens that essentially function as a silver-glass mirror first used nearly 200 years ago. Whether it be a simple ring light, digital enhancement, or a fully decked out Zoom room, the first impression one makes is often virtual and we all want to make it a good one. While industries such as travel and restaurants have been economically devastated from the pandemic, many fortunate people with financial means have savings that they are not spending on international travel, cruises, or the like, and can afford cosmetic surgery. Ophthalmic plastic and reconstructive surgery, or oculoplastics, is a focused subspecialty of ophthalmology focused on eyelid and periocular surgery. Surgeons are board-certified eye surgeons who spend an additional two years operating in this area — the most of any surgical specialty in medicine. Three common aesthetic eyelid procedures that oculoplastic surgeons perform include upper eyelid blepharoplasty for hooded upper eyelid skin, lower eyelid blepharoplasty for bags under the eyes, and ptosis repair for eyelids that are droopy due to a weakened muscle. Another unfortunately too common procedure that Oculoplastic surgeons perform is revisional eyelid surgery after a suboptimal outcome — often by a surgeon who does not regularly operate in this area. Upper eyelid blepharoplasty is the removal of upper eyelid skin and/or fat. This procedure is done for hooded eyelids that give a tired or fatigued look and can eventually get to the point where peripheral vision is impaired. This is a cosmetic procedure performed in the office setting. Subtle technical details of this procedure include measuring the right amount of skin to remove, incision placement (lower in a man), and the preservation of the muscle responsible for eyelid closure are critical to an optimal result. Lower eyelid blepharoplasty is a procedure performed for the treatment of lower eyelid bags. Traditional lower eyelid blepharoplasty included an external incision below the eyelashes and a dissection through the eyelid to access these fat pockets. In 2021, all contemporary surgeons performing lower eyelid blepharo-

Photos of patients with suboptimal outcomes after eyelid surgery. Left: The woman cannot close her eyes and has significant dry eye. Below: Patient who had eyelid surgery and required revisional surgery.

plasty should be well versed in the transconjunctival, scarless approach, which reduces the risk of complications and provides a quicker recovery. With this approach the incision is on the inside of the eyelid and the fat pockets can be modified as needed to give a smooth eyelid to cheek junction. Ptosis surgery is another common aesthetic and functional procedure performed by oculoplastic surgeons. Ptosis is a condition that every physician should be aware of, as it can be the sign of a paraneoplastic condition known as Horner’s Syndrome. This a condition when the actual eyelid is drooped and distinct from extra skin on the eyelid. Treatment of this condition involves strengthening the muscles that elevate the eyelid. The contemporary surgical approach for many patients with mild/ moderate amounts of ptosis avoids a scar and keeps a nice aesthetic contour. Unfortunately, many patients with ptosis end up getting blepharoplasty and present to the oculoplastic surgeon for secondary surgery. This is why a complete eyelid evaluation is necessary prior to eyelid surgery. With the surge of interest and limited oversight in cosmetic procedures, it is imperative that physicians and patients identify appropriately trained physicians for their particular cosmetic concern. Dr. Atul Gawande, a surgeon and regular contributor to The New Yorker, outlined the impact that checklists can make in reducing medical errors in his bestselling The Checklist Manifesto. Experienced sailors are also aware of the importance of planning with the saying that “90 percent of sailing errors occur before leaving the dock.” Just as every operating room uses a “timeout” to recheck the procedure and operative site, it is equally important to take the time find the right doctor for the right condition or operation. This checklist includes but is not limited to making sure they are board-certified in their area of practice, trained in the most contemporary techniques, committed to Maintenance of Certification (MOC), and that they are performing procedures within their true area of expertise. In the periocular region, every eye surgeon has seen the patient with chronic, uncomfortable dry eye and an inability to close their eyes as a

result of over an overzealous blepharoplasty. It is tragic to see someone looking for an aesthetic improvement now having to deal with a functional medical issue because they didn’t do their due diligence first. As we see now with this pandemic, medical literacy does not match having access to the internet. Patients often seek out procedures because someone has a strong Instagram or Facebook presence but fail to review the credentials of the person performing the procedure. We all know that procedural outcomes show a correlation with appropriate training and experience. As physicians committed to doing no harm, risk mitigation during this surge of cosmetic surgery begins with guiding patients to the right provider. Dr. Iyengar has been a member of SDCMS since 2014, and is an oculoplastic surgeon at San Diego Eyelid Specialists, and volunteer faculty with ORBIS International and its Flying Eye Hospital. Disclosure: Dr. Iyengar is a speaker for RVL Pharmaceuticals and a consultant for Horizon Pharma.

SanDiegoPhysician.org

PRACTICE MANAGEMENT

Open Notes in Healthcare The Good, the Bad, and the Ugly of the Cures Act BY CHAD ANGUILM, MBA, RICHARD F. CAHILL, JD, AND KATHLEEN STILLWELL, MPA/HSA, RN

N APRIL 5, 2021, a requirement of the 21st Century Cures Act went into effect: Patients must be able to access information in their EHRs “without delay.” (This requirement does not apply to paper records.) The Cures Act prohibition against information blocking, often referred to as an “open notes” provision, provides patients with transparency in the outcomes of their healthcare via convenient access to information in their EHR, which can positively or 14

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negatively impact the patient-doctor relationship. Patient access to records is not new, and neither is the Cures Act, which dates to 2016. What is new is the requirement that patients have electronic records access that is fast and easy. This requirement is expected to result in more patients — still a small proportion overall, but more patients — accessing additional EHR information, including providers’ notes. The requirement to provide patients

with EHR access raises questions for healthcare practices. Some questions are logistical, and some are relational. Concerns include the potential for increased time for patient education, or patient requests for changes to their records that the clinician cannot support. Healthcare providers should understand the good, bad, and ugly implications of the Cures Act open notes provisions so they can meet the requirements and reap their benefits, while avoiding the potential for fines or sanctions based on noncompliance or other negative impacts. Good News About Open Notes Many patients feel better about their provider after reading a note. Positive effects on the patient-provider relationship may be most significant among vulnerable patients, such as those with fewer years of formal education. Further, open notes have positive impacts on patient engagement and understanding. Patients report that reading notes is a way to better understand and

feel more in control of their healthcare. They also say it builds trust with their provider. The nonprofit organization OpenNotes (not a part of the Cures Act) cites helping laypeople maintain trust in scientific medicine as one benefit of the transparency created by the Cures Act open notes provisions. Bad News About Open Notes Concerns about open notes mainly revolve around the potential for conflicts with patients and potential time conflicts. Concerns include: • Timing: The originally planned implementation date for the open notes provisions in the Cures Act was November 2020. Because of the COVID-19 pandemic, this was pushed back to April 2021. However, many providers and practices are still feeling the pandemic’s effects, leading to the question: “Will new demands never end?” • Uncertainty about the documentation process: Most patients will not understand clinical shorthand, and providers may need added time for explanation. Providers are wondering: “How can I make my notes comprehensible to patients while still writing them quickly?” • Technology: Some EHR vendors are still racing to provide services that allow practices to remain in compliance with the Cures Act. It may be necessary for a provider to call their EHR vendor and say, “What are you doing to ensure my interoperability compliance?” Meanwhile, secure drop box options for records requests provide a workaround. Ugly News About Open Notes Some patient requests for record amendment are legitimate and easily handled. Some patients, however, will request removal of material they find embarrassing, even though it is accurate. More frequent requests for records changes from patients could increase already weighty administrative burdens on providers. Worse, some of these requests will be for changes providers cannot support, and making time for careful conversations with patients and providing written responses for

requests that are rejected will be a challenge. Inevitably, some of these conversations will not go well, whether through the patient feeling the provider did not adequately respond to their concerns, or through the patient insisting on unreasonable demands. These negative relationship outcomes will add emotional stress on both the patient and the provider, as well as a reputational threat to providers from angry patients posting negative reviews online. More tangibly, noncompliance with the open notes requirement carries the potential for fines, penalties, and/ or sanctions from medical boards. The specifics of potential penalties are not yet known—there are more changes coming with the Cures Act. Making Changes in Open Notes Patients will ask providers to amend their medical records. Be familiar with what the patient has the right to ask, what the provider can grant and/or refuse, and how to amend notes. Here are some highlights: • Patients have the right to request amendments to their medical records: The Health Insurance Portability and Accountability Act (HIPAA) requires a signed, dated request from the patient regarding what they want changed and why. • Providers have the right to determine whether the requested amendment will be made: The provider must respond, in writing, within 60 days of receipt of the patient’s request. • Common reasons to deny a patient’s request include that the provider who received the request did not create the record entry, or that the medical record is accurate as is. • The patient’s request and the provider’s response both become part of the patient’s medical record. Strategies for Success When composing notes, certain simple strategies will raise the odds that notes will be well understood and well received. Beyond being clear and succinct, strategies for success include composing at least a portion of the note as instructions directly addressed to the patient—“Start taking lisinopril and check your blood pressure twice a week,”

vs. “Initiated lisinopril and instructed her to check her blood pressure twice a week”—and providing a list of commonly used medical terms and abbreviations. For an in-depth review of strategies for success when composing notes, see 12 Strategies for Success With Open Notes in Healthcare: The Cures Act. Exceptions Unless an exception applies, clinical notes must not be blocked, but the Cures Act allows for a fairly long list of specific, well-delineated exceptions. For instance, a record can be blocked if a provider believes that viewing a note presents a substantial risk of harm to the physical safety of the patient or someone else. The Cures Act also recognizes exemptions that apply to certain caregiving situations, such as when parents attempt to access confidential parts of an adolescent child’s records. For information regarding exceptions to open notes, please see What Open Notes Exceptions Does the Cures Act Allow? Seeing Open Notes as Part of High-Touch, High-Value Care While many physicians and other providers have anticipated open notes with dread, most outcomes so far have been positive. Patients have reacted well to clarity. They have used open notes as a tool to improve their own understanding of and adherence to care instructions. When patients have noted valid issues or miscommunications, they have appreciated being able to quickly clear them up. More than an administrative burden, open notes present an opportunity to improve documentation, patient-provider relationships, and patient safety. By improving patient adherence to treatment plans, open notes have the potential to improve provider satisfaction as well. Chad Anguilm, MBA, is vice president, in-practice technology services, Medical Advantage, part of TDC Group. Richard F. Cahill, JD, is vice president and associate general counsel, The Doctors Company, part of TDC Group. Kathleen Stillwell, MPA/HSA, RN, is senior patient safety risk manager, The Doctors Company, part of TDC Group.

SanDiegoPhysician.org

COVID-19: SENIOR HEALTH

Clarity on COVID Count Pandemic’s Toll on Seniors Extended Well Beyond Nursing Homes BY JUDITH GRAHAM

S COVID-19 RESURGES

across the country, driven by the highly infectious delta variant, experts are extending our understanding of the pandemic’s toll on older adults — the age group hit hardest by the pandemic. New research offers unexpected insights. Older adults living in their own homes and apartments had a significantly heightened risk of dying from COVID last year — more than previously understood, it shows.

September 2021

Though deaths in nursing homes received enormous attention, far more older adults who perished from COVID lived outside of institutions. The research addresses essential questions: Which conditions appear to put seniors at the highest risk of dying from COVID? How many seniors in the community and in long-term care institutions might have died without the pandemic? And how many “excess deaths” in the older population can be attributed to COVID?

Of course, it’s already known that older adults suffered disproportionately. As of Aug. 4, more than 480,000 people age 65 and older perished from COVID — 79% of more than 606,000 deaths in the U.S. overall, according to the latest data from the Centers for Disease Control and Prevention. (This is likely an undercount because it relies on death certificate data that may not be up to date or accurately reflect the true toll of the virus.) Still, new information about older adults’ vulnerabilities is useful as COVID cases climb again and unvaccinated people remain at risk. Some key results from studies published over the past few months: Death Rates Varied Among Groups of Seniors In a study published in Health Affairs in June, experts from the Department of Health and Human Services analyzed data for more than 28 million people with traditional Medicare coverage from February 2020 (the approximate

start of the pandemic) to September 2020. (Excluded were about 24 million people in Medicare Advantage plans because data crucial to the study wasn’t available.) The researchers compared data for this period with previous years, dating to 2015. The study examines deaths among individuals with COVID and reaffirms headlines that have trumpeted the toll among older Americans. Medicare members diagnosed with COVID had a death rate of 17.5% — more than six times the death rate of 2.9% for Medicare members who evaded the virus. A notable finding in the study: Medicare members with dementia were especially vulnerable. If diagnosed with COVID, their death rate was 32%, compared with nearly 14% for those with dementia who weren’t infected. Also at substantially increased risk of death from COVID were older adults with serious and chronic kidney disease, immune deficiencies, severe neurological conditions, and multiple medical conditions. Most of the Seniors Who Died of COVID Lived Outside of Nursing Homes The HHS experts’ study reported 110,990 “excess deaths” due to COVID during the eight-month period it examined — most likely an undercount because many older adults who died may not have been tested or treated for the virus. The term “excess deaths” refers to a death count higher than the number expected based on historical data. It is a core measure of the pandemic’s impact. Of the excess deaths HHS experts documented, 40% occurred in nursing homes but a larger portion, nearly 60%, were seniors living in other settings. Other Studies Suggest Far More Excess Deaths Estimates of excess deaths in the older population vary widely depending on the period studied, the data sources used and the type of analysis conducted. Another study, published in May in the BMJ (formerly known as the British

Medical Journal), calculated 458,000 “excess deaths” in 2020 in the United States. About 72% were people 65 and older, according to the British and American authors. About two-thirds of these deaths can probably be attributed directly to COVID, the authors noted. Others might be due to acute medical care that was delayed during the pandemic, poor management of chronic medical conditions, the effects of isolation, and other factors. Assisted Living Residents Were Significantly Affected Data about the impact of the pandemic on assisted living residents has been scarce, in part because these facilities are regulated by states, not the federal government. A study out in June in JAMA Network Open found the death rate for assisted living residents in 2020 — as the pandemic unfolded — was 17% higher than in 2019. In the 10 states with the greatest community spread of COVID, the death rate for assisted living residents rose by 24%. “Efforts must be made to support assisted living communities as they work to address infection prevention and control to keep their residents safe,” says Kali Thomas, a study co-author and associate professor of health services, policy and practice at Brown University. Underlying Medical Conditions Played a Major Role A study by researchers from the Cleveland Clinic and the Health Data Analytics Institute in Dedham, Massachusetts, is one of the first to suggest how many older adults who caught COVID would have died from underlying medical conditions even if the pandemic had not been underway. It too examined 28 million people with traditional Medicare coverage from the approximate start of the pandemic (the end of February) through November 2020. (Of 28 million people in the study, more than 2.4% had a confirmed COVID diagnosis and 10% had a “probable COVID” diagnosis.) Other studies estimate excess deaths

by looking at population-wide data. This study looked at individual data, using a highly complex methodology to calculate a preexisting risk of death for each person based on his or her age, sex, medical conditions and other demographic characteristics. Actual deaths in 2020 were then compared with expected deaths based on those preexisting risks. The report has been published as a preprint without peer review. About 4% of Medicare members with confirmed or probable COVID who were living in the community, in their own homes and apartments, would have died anyway from underlying medical issues, the authors estimate. With COVID, the actual death rate climbed to 7.5%. In nursing homes and other long-term care facilities, 20.3% of residents diagnosed with confirmed or probable COVID would have died due to underlying medical issues; with COVID, that rose to 24.6%, the authors calculated. “This is a more accurate picture of the true toll of COVID,” says Dr. Daniel Sessler, chair of the department of outcomes research at the Cleveland Clinic. “As it turns out, the greatest increase in deaths [from the virus], in terms of both raw numbers and an increased risk of dying, was in the community, not in long-term care residents.” The Bottom Line About 80% of people 65 and older have been fully vaccinated, leaving millions of seniors still at risk of COVID. Special attention should be paid to older adults with dementia and other serious neurological conditions, kidney disease, and multiple medical conditions. Older adults, especially the eldest groups, who are frail and who live alone or with little support in areas where the virus is spreading rapidly also deserve special outreach and attention. Judith Graham is a columnist for MedPage Today, where this article first appeared. SanDiegoPhysician.org

SUPREME COURT

California Supreme Court Will Hear CMA Lawsuit Against Aetna Regarding the Right of Membership Organizations to Pursue Unfair Labor Practices BY CALIFORNIA MEDICAL ASSOCIATION STAFF

HE CALIFORNIA SUPREME

Court has granted the California Medical Association’s (CMA) petition for review in a lawsuit against Aetna surrounding the insurance company’s practice of denying patients’ rights to out-of-network benefits and threatening physicians who refer patients to out-ofnetwork providers. The decision is a major legal victory for CMA, and for patients throughout California. The California Supreme Court receives more than 1,000 civil petitions for review annually but only grants around 2-3% of those requests. In July 2012, CMA, along with the Los Angeles County Medical Association and a coalition of other healthcare organizations and providers, filed a lawsuit against Aetna to protect patients’ rights to quality healthcare and to prevent insurers from interfering with patient choice. The lawsuit alleges a systematic practice by Aetna of harassing and terminating contracted physicians from the Aetna network when they refer patients to out-of-

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network ambulatory surgery centers. In April 2019, after nearly seven years of protracted litigation, all plaintiffs except CMA agreed to dismiss their claims and Aetna agreed to abandon its counterclaims so that the lawsuit could be streamlined for CMA to proceed as the sole plaintiff. In November 2019, however, the Los Angeles Superior Court ruled that CMA did not have legal standing to pursue its claims against Aetna on behalf of itself and its physician members. The court appears to have erroneously concluded that CMA’s expenditures of its own resources didn’t count as injury to the organization because CMA “was founded to advocate on behalf of its physician members,” and that CMA staff time spent fighting these abuses “was typical of the support CMA provides its members in furtherance of CMA’s mission.” That conclusion is erroneous. California’s Unfair Competition Law (UCL) confers standing on any person or organization that “has suffered injury in fact and has lost money or property as a result of the unfair competition.” Aetna’s practices at issue in this case

both harmed CMA and its members and frustrated the other more expansive purposes of the organization, as CMA was forced to expend resources and money in order to protect its members from Aetna’s unfair practices. That is all that is required to establish standing under the UCL. If the appellate court’s decision is allowed to stand, it would effectively preclude any membership organization from ever seeking relief under the UCL and undercut a central plank of private enforcement of one of the state’s most important consumer-protection laws. CMA’s petition was supported by a broad coalition, including the American Medical Association, United Farm Workers of America, International Brotherhood of Teamsters Joint Council 7, California Labor Federation, Service Employees International Union California State Council, California Society of Anesthesiologists, La Cooperative Campesina de California, La Casa del Diabetico Gualan, and California Rural Legal Assistance Foundation.

POETRY AND MEDICINE

We’re born to this world of sensation And slowly make sense of the chaos The brain through selective creation Constructs its own meanings and bias

Signal From Noise BY DANIEL J. BRESSLER, MD, FACP

SIGNAL IS ENERGY

(electromagnetic, mechanical, acoustic, etc.) that contains meaningful data transmitted from one location to another, from a sender to a recipient. Noise is energy that accompanies a signal that dilutes or distracts from the comprehension of data by the recipient. The “signal-to-noise” ratio is a core concept in basic science and engineering. It has formal mathematical definitions in these fields based on the energy output of the transmission divided by the energy output of the extraneous or random background. Signal-tonoise ratio is also used informally to refer to the relative amounts of useful to distracting data, such as concert music versus crowd sounds, or words on a book page stained by coffee blotches. All living creatures maintain life through the process of disentangling signal from noise. Our biology is constructed to extract from the welter of incoming data that which can be used to help us survive and pass on our genes. We humans, with our unfathomably intricate brain,

analyze incoming data both from our senses as well as from thoughts themselves. In medicine, the need to disentangle signal from noise is ever-present, particularly in puzzling cases. In taking a history are we absorbing the key facts the patient is sharing and setting aside extraneous ones? In analyzing laboratory and imaging results, are we catching the explanatory clues and dismissing the red herrings? Does a finding that falls outside of the boundaries of normal indicate a disease process or simply an example of benign variation? Does the data create a pattern of threat or reassurance? Will additional testing be helpful, distracting, or even harmful? Answering those questions involves a continuous process of assigning degrees of salience to some findings and irrelevance to others. The skill with which we do this separates mastery from blundering. The accompanying poem applies this concept of signal-tonoise as a driver of neurogenesis, personal development, and societal progress. I hope you find in its rhyming stanzas both signal and entertainment.

How well does this process prepare us Through gambits of prompts and deploys? That depends how much error has spared us If we learn to parse signal from noise -----------------------------The inputs come ordered and random A tsunami of diamonds and dross Meaning and flak ride in tandem Rarely do lines of sight cross Yet out of this tower of Babel We build both our weapons and toys Whether life itself thrives or unravels Distinguishes signal from noise -----------------------------From chemosynaptic perfusion Converted to logic and cues The bundling of boundless profusion Into patterns we know and can use Reflections through houses of mirror Conveying both hits and decoys Conclusions that gradually grow clearer In filtering signal from noise. -----------------------------It’s a startling fact of our being, that The brain dwells in darkness and silence The miraculous fact of our seeing, comes Through trillions of pulsating islands We build up a sense of the world Through feedback, correction and poise Enlightenment slowly unfurled By partitioning signal from noise. Dr. Bressler, SDCMS-CMA member since 1988, is a former chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

SanDiegoPhysician.org

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.Gonzalez@ChampionsFH.org. CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal receive short term specialty care. Commitment can vary by practice. The mission of the Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew. Gonzalez@ChampionsFH.org, or visit www. ChampionsforHealth.org. PHYSICIAN OPPORTUNITIES

PER DIEM OBGYN LABORIST POSITION AVAILABLE IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency call at Scripps Memorial Hospital in La Jolla. 70 deliveries/month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com.

MEDICAL CONSULTANT – SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/careers/sdcounty?keywords=21416207 KAISER PERMANENTE SAN DIEGO - PER DIEM PHYSIATRIST: Southern California

September 2021

Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https://scpmgphysiciancareers.com/ specialty/physical-medicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at 866-503-1860 or Michelle.S1.Johnson@kp.org. We are an AAP/ EEO employer. CHULA VISTA VETERANS HOME SEEKS A STAFF PSYCHIATRIST: The Veterans Home of California - Chula Vista seeks a 30 hour/week Staff Psychiatrist. This facility contains three level of care for our 300 resident veterans: independent living, assisted living and skilled nursing. A Geropsychiatry background is recommended but not mandatory. More information may be reviewed at the following URL https://www. jobs.ca.gov/CalHrPublic/Jobs/JobPosting. aspx?JobControlId=221636 or you may email Paul D. Wagner, MD, FACP, Chief Medical Officer at paul.wagner@calvet.ca.gov. PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@ sdfamilycare.org or call us at (858) 810- 8700. FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times. PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director21226701UPH

NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/ HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org. PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other low-income, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org. FULL-TIME CARDIOLOGIST POSITION AVAILABLE: Seeking full time cardiologist in North County San Diego in busy established general cardiology practice. EP or Interventional also welcome if willing to hold general cardiology outpatient clinic also at least 50% of time while building practice. Please email resume to jhelmuth1220@gmail. com. Immediate opening. INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/physical medicine specialist with well-established orthopaedic practice. Position includes providing direct patient evaluation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and emr. Interested parties, please email lisas@sdsm.net. CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to evelynochoa2013@yahoo.com or via fax to (760) 510-1811. GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and

basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multi-specialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069. We are an equal opportunity employer and value diversity. Please contact Natalie Shields at (760) 2916637/nshields@graybill.org. You may view our open positions at: https://jobs.graybill.org/. BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, well-established East County San Diego (La Mesa) private Practice. We currently have an immediate part-time opening for a CA licensed Dermatologist to work 2-3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a full-service Dermatology office providing general, cosmetic and surgical services, including Mohs surgery and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV with salary expectation to patricia@grossmontdermatology.com PRACTICE FOR SALE

OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3,000 SF with 1 or 2 Physician Offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in house billing section, staff room and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at 858-354-1895 or email: mahdavim3@gmail.com OFFICE SPACE / REAL ESTATE AVAILABLE

OFFICE SPACE FOR MENTAL HEALTH PRACTITIONER: Available June 1st, 2021, Mercy Medical Building, one large consultation room facing eastern mountains, large windows, recently remodeled. Includes waiting room, plenty of storage, BR, parking for patients. Walking distance to UCSD medical center and Mercy Hospital and lots of restaurants. Freeway close. Contact Randall Hicks MD, at 619-298-7135. TURNKEY MEDICAL OFFICE FOR LEASE IN BRAWLEY, CA: 6,504 SF medical office space available at 283 Main Street Brawley, CA. Office includes a large reception area, 10 exams rooms, 5 offices, 5 restrooms, X-ray room, lounge, lab space and nurses station. Located on the main road with easy access and abundant parking. Available for a short or long term lease. Please call Melissa at 310-471-2700 for more information.

TURNKEY OFFICE SPACE FOR RENT NEAR ALVARADO HOSPITAL: Turnkey office space for rent. Modern, remodeled and clean. We have a little space available or a lot, depending on your needs. We are located near Alvarado hospital. Conference room, nurses station and many exam rooms, along with Doctors and Admin spaces. To inquire or to schedule a showing, please contact Jo Turner (619) 733-4068. OFFICE SPACE IN POWAY: Office in Poway. Centrally located. Close to Pomerado hospital. Radiology, pharmacy next door. Fully furnished, WiFi included. Three exam rooms, reception area, waiting room. Half days to full time available. Ideal for specialist who wants to expand. Call Dr. Luna if interested: (619) 472-1914. KEARNY MESA OFFICE FOR SUBLEASE: Kearny Mesa area sublease in our orthopedic office which includes: onsite x-ray available, storage space, space for 1-2 employees and free parking. Can discuss internet, phones, fax line, access to printer/copier, and more. Please contact Kaye Spotz at kspotz@synergysmg. com for more information. SAN DIEGO OFFICE NEAR SHARP FOR SUBLEASE OR TO SHARE: Rady Children’s Hospital medical office building at 7910 Frost Street. Central location near to both Rady Children’s Hospital and Sharp Memorial Hospital, between HWY 163 and I-805. Available to any specialty. The space available includes access to one office, two exam rooms and a nurse’s station / common area desk. Be close to excellent referral sources in the building and from the hospital campus. If you have an interest or would like more information, please call (858) 278-8300 x. 2210 or email nhughes@synergysmg.com UTC AREA MEDICAL OFFICE SPACE: 2000 sq. ft. Recently renovated corner office space in La Jolla Medical & Surgical Center at 8929 University Center Lane. Beautiful building with ample free parking. One mile from UCSD Jacobs Health Center and Scripps Memorial Hospital. Prime location. Competitive rent. Contact (858) 337-3768 or Email Marcekramer@me.com

MEDICAL EQUIPMENT / FURNITURE FOR SALE

MEDICAL EXAM TABLES FOR SALE: Unfortunately for us, we are unable to utilize our medical exam tables which are in great condition. Our practice is going in a different direction, thus the need for us to provide these tables, which were barely used. The tables are approximately 70 x 30 inches and have black padding on top of a natural pine wood frame. Each table adjusts up and has a headrest with a pillow included. We are interested in moving these out of our office as soon as possible, since we are remodeling and need the space to complete the project. We can provide a picture and schedule time to see the tables between 9am - 5pm M-Th, or 9am - 2:00pm Friday. Price is negotiable and we are just looking for a reasonable donation for the tables. We can sell individually as well, but will provide a greater incentive for taking both. Please contact Rick at 619-795-6700 or email rick@ manageyourage.com. OBGYN RETIRING WITH OFFICE EQUIPMENT FOR DONATION: Retiring from practice and have the following office equipment for donation: speculums, biopsy equipment, lights, exam tables with electric outlets, etc. Please contact kristi. eisenhauermd@yahoo.com or (760) 753-8413. MEDICAL EQUIPMENT FOR SALE: 2 Electric tables one midmark, 3 Ultrasounds including high resolution Samsung UGHE60 with endovag and linear probes, STORTZ hysteroscopy equipment, 2 NOVASURE GENERATORS ,ENDOSEE OFFICE HYSTEROSCOPY EQUIPMENT : NEW MODEL, OLDER MODEL, Cynosure laser equipment: MONALISATOUCH (menopausal atrophy), TEMPSURE Vitalia RF (300 watts!) for incontinence, ENVI for face, Cynosure SculpSure with neck attachment for body contouring by warm sculpting. Please contact kristi. eisenhauermd@yahoo.com or 760-753-8413. FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs-137. Rod Std 2. Cs-137. DCRS 3. Cs-137. Spot 4. Co-57. Flood sheet. Please contact us at (760) 730-3536 if interested in purchasing, pricing or have any questions. Thank you.

OFFICE SPACE / REAL ESTATE WANTED NON-PHYSICIAN POSITIONS WANTED

MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact (858) 633-6959.

MEDICAL OFFICE MANAGER/CONTRACTS/ BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo. com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work.

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